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December 20, 2017

The new blood pressure guidelines aim to save lives—but is there a downside?

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    Updated hypertension guidelines released last month aim largely to "scare people into changing their behavior"—a tactic that research suggests won't work, according to Aaron Carroll, a pediatrics professor who blogs on health research and policy. 

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    Last month, the American Heart Association and the American College of Cardiology released guidelines that lower the threshold for high blood pressure from 140/90 mm Hg to 130/80 mm Hg. Under the new guidelines, 45.6% of U.S. residents—or roughly 103.3 million individuals—have high blood pressure, according to the guideline authors. Under the old guidelines, about 31.9% of U.S. residents—or 72 million people—had high blood pressure.

    New guidance did nothing 'drastic'

    In the New York Times' "The Upshot," Carroll takes issue with the media coverage of the updated guidelines, saying much it "made it sound as if something drastic had happened overnight." Carroll writes, "Nothing had. We just changed the definition of hypertension."

    Carroll draws attention to the data used for the new guidelines. The data came from a Sprint study, which enrolled more than 9,300 patients who were at least 50 years old who had systolic blood pressure—the top number on the reading—between 130 to 180. Half of the patients received standard care, meaning they were to keep their systolic blood pressure under 140. The other group was told to get their blood pressure below 120, which Carroll notes "of course, required more therapy, mostly of the pharmacologic nature."

    The Sprint study, published in 2015, found that acute cardiovascular events and death were less common among patients in the intensive therapy group. However, Carroll notes, "the fact that those in the intensive therapy group also had more adverse events, like hypotension, syncope, and acute kidney injury, got less attention."

    Nonetheless, he adds that the Sprint study "is a significant trial, and we should treat it seriously"—but we should not "generalize its results" without paying close "attention to the details of its methods." He points out that the Sprint study participants, in addition to being over 50 and having systolic pressure between 130 and 180, "had to have ... another subclinical cardiovascular disease, chronic kidney disease or a Framingham 10-year risk of cardiovascular disease of 15% or more," or be older than 75.

    Further, participants' blood pressure had to be confirmed in three separate readings to avoid "white coat hypertension"—or when a patient's blood pressure rises because they're nervous to have it read in a clinical setting. Given the potential for white coat hypertension, blood pressure-checking guidelines call for multiple readings outside of the office after a concerning office reading—though "this happens far too rarely," Carroll writes. "Instead, people get their blood pressure measured quickly in the office, are labeled hypertensive, and are then put on treatment pathways," he explains.

    By contrast, while the Sprint "showed that people truly at high risk should have their blood pressure managed more aggressively than we thought, ... that has not been the message of news on the new guidelines." The message "has focused far more often on the many newly reclassified people with mild blood pressure, who were not the focus of the Sprint intervention," Carroll states.

    Noting that "almost none of the newly labeled hypertensive people ... should be placed on medications" and instead "should be advised to eat right, exercise, drink responsibly, and not smoke," Carroll questions the reasoning for altering the guidelines. He states, "Is there anyone left who doesn't know those things are important for good health?"

    'We're … already oversaturated with worry'

    Carroll quotes an accompanying article for the guidelines that argues the update "'has the potential to increase hypertension awareness, encourage lifestyle modification, and focus antihypertensive medication initiation and intensification on U.S. adults with high' cardiovascular disease risk."

    However, Carroll says the guidelines' goals are largely, ," to make news and potentially scare people into changing their behavior"—a tactic that Carroll argues "has not been shown to work, at least not for all diseases." He cites a 2015 meta-analysis published in the Psychological Bulletin. The authors concluded that "fear appeals could change attitudes, intentions and behaviors, but mostly on issues with a high susceptibility and severity." When it comes to hypertension, Carroll writes, "It's hard to believe we're not already oversaturated with worry."

    Carroll posits that while most of the people who are newly classified as hypertensive "should focus on how they live" rather than taking medication, "[m]ore people will probably be prescribed drugs because they've been told to be afraid and because they can't get their blood pressure low enough with diet and exercise" (Carroll, New York Times, "The Upshot," 12/18).

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